|Ahead of print publication
Anxiety, knowledge, attitude, and preventive practices toward COVID-19 among patients with psychiatric illness – A comparative study from South India
Preethy Raghuraman1, Manjula Simiyon1, Vishnu Vardhan Rudravaram2, Manikandan Mani1, Pradeep Thilakan1
1 Departments of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Statistics, Pondicherry University, Puducherry, India
|Date of Submission||09-Nov-2021|
|Date of Decision||16-Dec-2021|
|Date of Acceptance||27-Dec-2021|
|Date of Web Publication||15-Mar-2022|
Heddfan Psychiatric Unit, Betsy Cadwaldr University Health Board, Wrexham LL 13 7TD, North Wales
Source of Support: None, Conflict of Interest: None
Background: Coronavirus disease 2019 (COVID-19) pandemic has induced serious threats to people's mental health. There are increasing concerns about anxiety linked with COVID-19. There are very few studies conducted to understand the needs of the mentally ill during this pandemic. Aim: The study aimed to assess and compare the anxiety, knowledge, attitude, and preventive practices related to COVID-19 among people with and without psychiatric illnesses. Materials and Methods: A cross-sectional analytical study was conducted among patients with psychiatric illnesses and their caregivers in the psychiatry department of a tertiary hospital. All consenting adults with a diagnosed psychiatric illness and scoring < 3 in the Clinical Global Impression-Severity scale were included in the case group. All consenting adult caregivers who accompany the patients were included in the reference group. Coronavirus Anxiety Scale and Knowledge, Attitude, and Preventive Practices towards COVID-19 Questionnaire were administered. Data were analyzed using IBM SPSS (19.0 version). Results: Less than 10% of the participants in both the groups had COVID-related anxiety. 98.3% of the participants in both the groups knew that isolation and treatment of COVID-19-affected individuals can prevent the spread of the virus. Avoidance of handshaking (case – 85% and reference – 81.7%) and going out of home unnecessarily (case – 83.3% and reference – 81.7%) were the predominant preventive practices in both the groups. Only, the attitude had a statistically significant difference between both the groups (P < 0.05). Conclusion: Patients with psychiatric illness had fair knowledge, and they followed preventive practices toward COVID-19 that are comparable with healthy individuals. There were discrepancies between their knowledge and preventive practices.
Keywords: Attitude, COVID anxiety, India, knowledge, preventive practices
|How to cite this URL:|
Raghuraman P, Simiyon M, Rudravaram VV, Mani M, Thilakan P. Anxiety, knowledge, attitude, and preventive practices toward COVID-19 among patients with psychiatric illness – A comparative study from South India. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Mar 30]. Available from: https://www.anip.co.in/preprintarticle.asp?id=339660
| Introduction|| |
The coronavirus disease 2019 (COVID-19) epidemic emerged in Wuhan, China, at first spread countrywide and then onto other nations including India between December 2019 and early 2020. The COVID-19 outbreak was announced as a public health emergency of international concern on January 30, 2020. While writing this paper (November 03, 2021), the number of cases according to the World Health Organization (WHO) is 246,951,274 and 50,004,855 deaths worldwide which has spread to more than 200 countries. India confirmed its first case on January 30, 2020. Since then, many measures have been taken to contain the spread of the virus. After a 14-hours voluntary public curfew on March 22, a 21-day lockdown was announced till April 14, which was later extended as the number of cases increased. The total number of COVID-19 cases in India is 34,296,237 and 458,880 deaths (November 03, 2021).
The present corona pandemic causes extraordinary physical and economic challenges. The COVID-19 pandemic has induced serious threats to people's physical health, mental health, and lives. Numerous people suffer from uncertainty, fear of infection, moral agony, and grief, frequently experienced alone. This corona pandemic is expected to cause a variety of psychiatric morbidities, including depression, anxiety, panic attacks, psychomotor excitement, psychotic symptoms, delirium, and even suicidality. Increasing concerns about anxiety linked with COVID-19 have led to recommendations for efficacious self-care, and wider accessibility of mental health treatment. We are already witnessing that COVID-19 can escalate anxiety in those with a history of traumatic isolation, or obsessive–compulsive disorder, or chronic schizophrenia. Although there has been considerable attention to actions to spot people with this infection, identifying the mental health-care needs of people affected by this pandemic has been relatively ignored. Hence, attending to the mental health of citizens in general and specifically the vulnerable population is imperative.
Knowledge of the COVID-19 symptoms, high-risk conditions/practices, and the prognosis is highly important to control the pandemic. We must practice avoidance of contact with contaminated surfaces/hands/objects, regular washing of hands, maintaining physical distances, taking precautions while coughing/sneezing, utilizing an alcohol-based rub, and other protective equipment. People's adherence to preventive practices is affected by their knowledge, attitudes, and practices toward COVID-19. A recent article explained that various factors such as cognitive dysfunction, lower educational attainment, and lower health literacy compared to the general population and their difficulties related to appraising the information and applying them make the patients with psychiatric illnesses more vulnerable for COVID-19. The authors also had concerns that patients with severe mental illnesses may present for medical attention much later in the course of the disease. In developing countries like India, creating sufficient awareness and addressing their anxiety and misconceptions are highly essential. We could come across studies assessing the mental health of the general population, and health-care workers, during the pandemic. Despite the increased requisite to understand the needs of mentally ill patients, we could come across very few studies related to that.,,
The majority of the studies published were online or web-based or telephonic surveys that could have addressed only the educated population.,, Even though the majority of the Indian population has access to the Internet, only a limited population can complete an online survey. Furthermore, studies have used questionnaires to assess anxiety in general, which may not be specific to COVID-related anxiety. Some of the studies, which assessed attitude, had used questions related to knowledge rather than attitude. As attitude is the feeling or opinion about someone or something, we designed questions addressing the same. There were reports from South India when the public protested against burying the corpse of a doctor who died of COVID-19 and landlords vacating the doctors from their houses.,
Through this study, we aimed to assess and compare the anxiety, knowledge, attitude, and preventive practices related to COVID-19 among people with and without psychiatric illnesses during the peak of the first wave of COVID-19 pandemic in 2020 with strict lockdown measures. The findings have the potential to unearth the differences in mental health needs in people with and without psychiatric illnesses during the pandemic and help to develop policies for the future outbreak of pandemics if any.
| Materials and Methods|| |
A cross-sectional analytical study was conducted among patients with psychiatric illnesses and their caregivers in the department of psychiatry, a tertiary care hospital in Puducherry, India. The Institutional Human Ethics Committee approved the study on July 13, 2020 (RC/2020/57).
All consenting adult patients visiting the psychiatric outpatient department of a tertiary care center and those who had a Clinical Global Impression-Severity (CGI-S) score of <3 were included in the case group. All consenting adult caregivers who accompany the patients visiting the psychiatric department were included in the reference group. Among the caregivers, those who had psychiatric illnesses, cognitive impairment, hearing, or visual impairment that can prevent them from meaningfully participating in the interview were excluded. The study was conducted from August 2020 to October 2020 following all the protocols for COVID-19.
The sample size was calculated based upon a study with an expected prevalence of COVID-related anxiety of 26.2% in those who have a psychiatric illness and 7% in those who do not have a psychiatric illness, with absolute precision of 5% and study power of 80%. The required sample size per group was 58. Hence, we included 60 participants in the cases and 60 participants in the reference group.
A semi-structured pro-forma was used to collect information about sociodemographic details of both cases and caregivers. Cases were screened with CGI-S scale. The CGI provides an overall clinician-determined summary measure that takes into account all accessible information, including knowledge of the history of patients, psychosocial conditions, symptoms, behavior, and the effect of the symptoms on the patient's ability to function in the last 7 days which is a seven-point scale. This was used to screen and select those patients who were not severely ill.
Coronavirus Anxiety Scale (CAS) is a short mental health screener to detect probable cases of dysfunctional anxiety associated with the COVID-19 crisis. This is a five-item scale wherein the responses range from “not at all” to “nearly every day over the last 2 weeks.” It is based on the Diagnostic and Statistical Manual of Mental Disorders 5's cross-cutting symptom measure, adult self-rated version. The CAS differentiates well between persons with and without dysfunctional anxiety using an optimized cutoff score of 9 (90% sensitivity and 85% specificity).
Knowledge, Attitude, and Preventive Practices toward COVID-19 Questionnaire was devised by the authors by modifying two prevalidated questionnaires, after a comprehensive literature search and based on the most recently available information from the WHO and the Indian Council of Medical Research relevant to the Indian context. The range of scores for knowledge was 0–12, attitude was 3–15, preventive practices was 0–32, and anxiety was 0–20.
Descriptive statistics were used to describe the sample in terms of frequency and cross-tabulations. As the data were not normally distributed, we used nonparametric tests. Mann–Whitney U-test was used to compare the scores of anxiety, knowledge, attitude, and preventive practices between the case and reference groups. Statistical significance was set at P < 0.05. All data analysis was performed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.).
| Results|| |
Sociodemographic profile of the participants
The mean age of participants in the case group was 38 years (38 ± 11). The majority of them were married (38 [63.3%]) and belonged to the Hindu religion (51 [85.0%]). More than half of the participants in the case group belonged to the middle socioeconomic class (43 [71.7%]) and hailed from rural areas (39 [65.0%]).
The mean age of participants in the reference group was 41 years (41 ± 13). A greater number of participants in the reference group were married (42 [70.0%]) and belonged to the Hindu community (44 [73.3%]). The majority of them belonged to the middle socioeconomic class (42 [70.0%]) and hailed from rural areas (39 [65.0%]). Forty-four of them were parents of the patients, 2 were siblings, and 14 were spouses of the patients [Table 1].
Psychiatric diagnosis of the participants
Among the 60 cases, 52 (86.66%) were follow-up cases. The most prevalent psychiatric disorders in the case group were mood disorders (25 [41.7%]), schizophrenia and other psychotic disorders (15 [25.0%]), and OCD and other anxiety disorders (14 [23.3%]). Fifteen percent of the participants had more than one psychiatric diagnosis [Table 2].
Physical illness among the participants
Among the case group, 21 (35.0%) had a physical illness, and among the reference group, 14 (23.3%) had a physical illness. Among the case group, 16.7% had diabetes and 8.3% had hypertension. In the reference group, 20.0% had diabetes and 11.7% had hypertension.
Knowledge about the COVID-19
The median score of knowledge about COVID-19 in both the case and reference groups was 10 (IQR [case] – 1.0 and IQR [reference] – 1.5). About 59 (98.3%) respondents in both the groups knew that isolation and treatment of COVID-19-affected individuals can prevent the spread of the virus, while 58 (96.7%) in the case group and 59 (98.3%) in the reference group were aware that one should avoid going to crowded places to reduce the spread of the virus [Table 3]. There was no statistically significant difference between the case and reference groups.
|Table 3: Statements and responses assessing knowledge about COVID-19 among the cases and the reference groups|
Click here to view
Attitude towards COVID-19
The median score of attitude towards COVID-19 among the case group was 5 (IQR – 4.0) and among the reference group was 4 (IQR – 4.0). The lower the score, the better was the attitude [Table 4]. The reference group had a better attitude (lower score) which was statistically significant (P = 0.031).
|Table 4: Statements and responses assessing attitude towards COVID-19 among the cases and the reference groups|
Click here to view
Preventive practices against the COVID-19
The median score of preventive practices was found to be 28 (IQR [case] – 5.0 and IQR [reference] – 3.0) in both the case and reference groups. Avoidance of handshaking (case – 85% and reference – 81.7%) and going out of home unnecessarily (case – 83.3% and reference – 81.7%) were the dominant preventive practices in both the groups. The least common preventive measures between both the groups were cleaning hands with soap/sanitizer (case – 20% and reference – 26.7%) and avoidance of proximity (case – 50% and reference – 43.3%) [Table 5]. There was no statistically significant difference between the scores of preventive practices of the two groups.
|Table 5: Statements and responses assessing the preventive practices against COVID-19 among the cases and the reference group|
Click here to view
Anxiety toward COVID-19
The median score of anxiety related to COVID-19 among the case and reference groups was found to be 3 (IQR [case] – 6.0 and IQR [reference] – 3.0). Five cases and one among the reference group had scored 9 and above in CAS indicating dysfunctional anxiety [Table 6]. The anxiety score did not differ between both the groups.
|Table 6: Statements and responses assessing anxiety about COVID-19 among the cases and the reference groups|
Click here to view
| Discussion|| |
Epidemics and pandemics are periodic phenomena. People face several challenges during such periods. Lack of awareness frequently leads to an unconcerned attitude, which may unfavorably affect the preparedness to encounter these challenges. The fear and anxiety related to pandemics also affect the behavior of people in the community. Hence, this study attempted to assess the anxiety, knowledge, attitude, and preventive practices toward COVID-19 among people with and without psychiatric illnesses attending a tertiary care hospital in South India.
Many studies have been conducted to assess the knowledge, attitude, and preventive practices toward COVID-19 among health-care workers or the general population.,,, Not many studies have focused on COVID anxiety among psychiatric patients, which is a vulnerable population. The COVID-19 pandemic is a challenge for all of us irrespective of their age, gender, or socioeconomic status. Nonetheless, people with mental illness may encounter greater difficulties due to the complex factors making this population vulnerable to COVID infection and complications. We also have to consider the impact of global and national public health measures and their impact on the delivery of mental health care.
A significant proportion of the case (95%) and reference (88.33%) groups knew the main clinical symptoms of COVID-19; only 30% in the case group and 28.33% in the reference group were able to identify symptoms (stuffy nose, runny nose, and sneezing) that distinguish it from the common cold. Confusing the symptoms of COVID-19 with a common cold could challenge the practice of early treatment seeking when COVID-19 is associated with common cold-like symptoms. Our findings were in line with a study conducted among the visitors of Jimma University Medical Center, Ethiopia, which found that 83% knew the main clinical symptoms of COVID-19 and only 37.7% were able to distinguish COVID-19 from the symptoms of the common cold.
Concerning the modes of transmission, a good proportion of both the case (93.33%) and reference (93.33%) groups knew that the virus spreads via respiratory droplets of infected individuals. However, only 56.67% among the case group and 65% among the reference group knew that asymptomatic people even without fever can also transmit the virus. This knowledge is very important as it will impact their behavior in places where the apparent risk of COVID-19 is not explicitly present. Similarly, only 60% in the case group and 53.33% in the reference group knew that COVID-19 can also spread through inanimate objects. An online study conducted among social media users by Dkhar et al. in Jammu and Kashmir, India, showed that 89% were aware of all modes of transmission. Previously conducted studies have found that around 90% of the participants were knowledgeable about the modes of transmission., Another Indian study, which assessed the knowledge about COVID-19 among patients with clinically stable severe mental illness, found that two-thirds of the participants had poor knowledge of precautionary measures against COVID-19. Again, this was a cross-sectional telephonic survey.
Regarding the knowledge about risk factors, the majority of them (case – 86.67% and reference – 86.67%) knew that the geriatric population, those suffering from chronic illnesses, and obese people are more likely to develop severe COVID-19 symptoms requiring intensive care. Since the knowledge on this aspect is good, it is more likely that people at risk will approach the medical facilities at the earliest, which can in turn improve their prognosis.
In our study, we found that in both the case and reference groups, the majority of them were knowledgeable about the preventive methods to combat the spread of COVID-19. However, this was not reflected in the preventive practices followed by them. Around 98.3% in the case group and 96.7% in the reference group were knowledgeable that avoidance of going to crowded places can prevent the spread of COVID-19. However, only around 50% of the participants in both the groups were not going to crowded places. Their knowledge is not reflected in the practices making it less meaningful. Moreover, only 20% in the case group and 26.7% in the reference group were washing hands with soap/alcohol-based sanitizer frequently. In a densely populated country like India, several reasons can be pointed as to why people find it difficult to regularly follow preventive practices: the living situation is usually overcrowded, lack of adequate water supply, unemployment, illiteracy, and frequent gatherings for worship. If the above knowledge is implemented in preventive practices carried out by the people, the spread can be more effectively controlled.
In our study, the attitude toward COVID-19 was fairly good, only a lesser percentage of people were having a negative attitude [Table 4]. However, the behavior seen in our society was not favorable. This could be because doctors conducted the interview and this could have prevented the participants from being candid about how they feel. Another possibility could be, as this sample represented people who meet the health-care professionals very often for their mental health-care needs, they may have a positive attitude, with regards to statement 3 [Table 4]. Only, attitude had a statistically significant difference between both the groups. There were not many differences between other outcomes among the two groups. This could be probably because all of them belong to the same families and may share similar practices and beliefs.
Our study found that only 8.3% in the case group and 1.7% in the reference group had dysfunctional anxiety towards COVID-19. A study done by Choi et al. among Hongkong people revealed that 14% had anxiety during the COVID outbreak. Another study done by Özdin and Bayrak Özdin in Turkey found that 45.1% had anxiety related to the COVID-19 pandemic. Another study from India found that the anxiety levels were high and more than 80% were preoccupied with the thoughts of COVID-19. However, the above-mentioned study was an online study, and people who have access to the Internet alone could participate. These are usually educated populations who express anxiety cognitively. Furthermore, it was done at the beginning of the pandemic and published in April 2020 when the perception among the public would have been different.
After a thorough literature search, we decided to use CAS in our study as there were not many scales available to assess COVID anxiety specifically. We found that many studies have used the Generalized Anxiety Disorder 7-item scale, Hospital Anxiety and Depression Scale, and Depression Anxiety Stress Scale to assess COVID anxiety.,, But later during the course of the research, we realized that CAS assesses only physical symptoms of anxiety, which was not common in our population. That could be the reason why very few had dysfunctional anxiety in our study. During the interviews, we could perceive that many of them were preoccupied with the pandemic and its implications. Secondly, this study evaluated only people who visited the psychiatry outpatient services at that time period and their long-term psychological impacts were not assessed. Thirdly, we have included only those who had stable mental health for the feasibility of the study; hence, this may not represent those who are currently severely ill.
Designing suitable research tools to assess anxiety among the Indian population is of paramount importance. Furthermore, a qualitative research design addressing their concerns would be an eye-opener to the experiences of this vulnerable group. The authors are working on a qualitative study to explore patients' difficulties and anxieties, which could not be evaluated in this quantitative questionnaire-based study.
| Conclusion|| |
Patients with psychiatric illness have a fair knowledge and follow preventive practices towards COVID-19 that are comparable to healthy individuals. Less than 10% of the subjects in both the case and reference groups had COVID-related anxiety. Patients with psychiatric illnesses have a comparable understanding of the pandemic and ways to control the spread as to the general population.
We thank our colleagues in our department who have given valuable suggestions and our participants who co-operated with us during COVID times.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatry 2020;33:e100213.
India: WHO Coronavirus Disease (COVID-19) Dashboard with Vaccination Data. Available from: https://covid19.who.int
. [Last accessed on 2021 Nov 03].
Peteet JR. COVID-19 anxiety. J Relig Health 2020;59:2203-4.
Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al.
Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry 2020;7:228-9.
Kebede Y, Yitayih Y, Birhanu Z, Mekonen S, Ambelu A. Knowledge, perceptions and preventive practices towards COVID-19 early in the outbreak among Jimma university medical center visitors, Southwest Ethiopia. PLoS One 2020;15:e0233744.
Zhong BL, Luo W, Li HM, Zhang QQ, Liu XG, Li WT, et al.
Knowledge, attitudes, and practices towards COVID-19 among Chinese residents during the rapid rise period of the COVID-19 outbreak: A quick online cross-sectional survey. Int J Biol Sci 2020;16:1745-52.
Shinn AK, Viron M. Perspectives on the COVID-19 pandemic and individuals with serious mental illness. J Clin Psychiatry 2020;81:20com13412.
Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health 2020;17:1729.
Li Z, Ge J, Yang M, Feng J, Qiao M, Jiang R, et al.
Vicarious traumatization in the general public, members, and non-members of medical teams aiding in COVID-19 control. Brain Behav Immun 2020;88:916-9.
Chew NW, Lee GK, Tan BY, Jing M, Goh Y, Ngiam NJ, et al.
A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain Behav Immun 2020;88:559-65.
Shi Y, Wang J, Yang Y, Wang Z, Wang G, Hashimoto K, et al.
Knowledge and attitudes of medical staff in Chinese psychiatric hospitals regarding COVID-19. Brain Behav Immun Health 2020;4:100064.
Hao F, Tan W, Jiang L, Zhang L, Zhao X, Zou Y, et al.
Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. Brain Behav Immun 2020;87:100-6.
Zhou J, Liu L, Xue P, Yang X, Tang X. Mental health response to the COVID-19 outbreak in China. Am J Psychiatry 2020;177:574-5.
Fernández-Aranda F, Casas M, Claes L, Bryan DC, Favaro A, Granero R, et al.
COVID-19 and implications for eating disorders. Eur Eat Disord Rev 2020;28:239-45.
Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan A, et al.
Psychological impact of COVID-19 lockdown: An online survey from India. Indian J Psychiatry 2020;62:354-62. [Full text]
Rehman U, Shahnawaz MG, Khan NH, Kharshiing KD, Khursheed M, Gupta K, et al.
Depression, anxiety and stress among Indians in times of COVID-19 lockdown. Community Ment Health J 2021;57:42-8.
Muruganandam P, Neelamegam S, Menon V, Alexander J, Chaturvedi SK. COVID-19 and severe mental illness: Impact on patients and its relation with their awareness about COVID-19. Psychiatry Res 2020;291:113265.
Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatr 2020;51:102083.
Busner J, Targum SD. The Clinical Global Impressions scale: Applying a research tool in clinical practice. Psychiatry (Edgmont) 2007;4:28-37.
Lee SA. Coronavirus anxiety scale: A brief mental health screener for COVID-19 related anxiety. Death Stud 2020;44:393-401.
Dkhar SA, Quansar R, Saleem SM, Khan SM. Knowledge, attitude, and practices related to COVID-19 pandemic among social media users in J&K, India. Indian J Public Health 2020;64 (Suppl):S205-10.
Choi EP, Hui BP, Wan EY. Depression and anxiety in Hong Kong during COVID-19. Int J Environ Res Public Health 2020;17:E3740.
Özdin S, Bayrak Özdin Ş. Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: The importance of gender. Int J Soc Psychiatry 2020;66:504-11.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]